Diagnostic Assessment — Thoracic Soft Tissue Injury
Example 1 of 1 · fictitious patient
Diagnostic Assessment Thoracic Soft Tissue Injury BOP Code: 28 of 2020 (Sprain and Strain) RH Code: 27 of 2020 (Sprain and Strain)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Air Force as an Aircraft Technician from 3 September 1989 to 19 June 1996
Occupational History
As an Aircraft Technician, the veteran's duties included physically demanding tasks aboard service vessels and at shore establishments.
He was also required to participate in military sporting activities including rugby, which involved high-impact collisions with risk of thoracic injury
History
The veteran sustained a ligamentous injury affecting the cervical and lumbar spine on approximately 1 February 1990 during a rugby game at a maintenance squadron, when a scrum collapsed on top of him.
The examination documented tenderness of the cervical and lumbar spine, the paraspinal muscles and the left scapula, which overlies the upper thoracic cage, indicating that the thoracic region was involved in this early injury.
Further thoracic exposure occurred on 23 November 1993, when a car slid off a jack and pinned him by the shoulders while he was changing a flat tyre on his way home from work (a strain of the left scapular and upper back muscles was diagnosed on 30 November 1993), and on 5 July 1994, when he slipped on duty and landed on a floor polisher, bruising the right posterior ribs
Timeline
01 Feb 1990 — Aircraft Technician the veteran, as a young adult, sustained a ligamentous back injury from rugby at a maintenance squadron during initial recruit training.
Examination documented tenderness over the cervical and lumbar spine with paraspinal muscles, and over the left scapula, which overlies the upper thoracic cage.
The thoracic spine lies between the documented areas of cervical and lumbar tenderness, and it is probable that the thoracic region was also involved in this significant spinal injury.
The examination did not specifically exclude the thoracic spine.
Under DVA legislation, the absence of documentation does not mean something did not occur. "Ligamentous back injury" 23 Nov 1993 — ABSR the veteran, as a young adult, was pinned by the shoulders under a car when the jack shifted while he was repairing a flat tyre on his way home from work (the injury was recorded as not on duty).
The compressive force through the shoulders would load the upper thoracic spine.
Pain in the spine was specifically documented. "Soft tissue injury" 30 Nov 1993 — ABSR the veteran, as a young adult, presented with an injury to the left upper back three days earlier, initially treated with Brufen 400mg and local heat, which had improved slightly and then deteriorated, especially when going up and down stairs in ships.
Examination showed tenderness over the left scapular region and upper back muscles with full movements; a strain of the musculature was diagnosed and treated with Voltaren 50mg twice daily and Messal cream, and he was excused duty. "Injured L upper back 3/7 ago" 05 Jul 1994 — ABSR the veteran, as a young adult, slipped on wet soapy water while scrubbing a deck before polishing at FIMA Alexandria and landed on the floor polisher and his back, on duty.
Examination showed tenderness of the right posterior ribs 9 to 12, which articulate with the lower thoracic vertebrae, and of L4 to S1, and X-rays of the ribs and lumbosacral spine were ordered. "Bruised (R) ribs post"
Symptoms
At the time of injury, the veteran had pain in his back and neck, with tenderness of the cervical and lumbar spine, the paraspinal muscles and the left scapula, which overlies the upper thoracic cage.
The injuries were severe enough to require light duty and NSAID treatment
Imaging
02 Mar 2022 — X-ray thoracic spine: "Multilevel degenerative disc disease at distal thoracic levels.
Mildly anteriorly wedged T11." 18 Aug 2019 — MRI thoracic spine: "Moderate multilevel thoracic spondylosis.
T8/9 3.5mm central disc protrusion with mild ventral cord indentation."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Thoracic Soft Tissue Injury (ICD-10: S29.009A).
The relevant Statements of Principles are those concerning Sprain and Strain (Balance of Probabilities No.
28 of 2020; Reasonable Hypothesis No.
27 of 2020), applied by analogy as this is a DRCA claim
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 1 February 1990 [ [CHART REVIEW document], pages 16 17] When did the veteran first present to a health / medical provider for this condition? Approximately 1 February 1990 When was the condition confirmed / formally diagnosed? Approximately 1 February 1990 When did the veteran first present to you (or your practice) for this condition? 14 January 2021
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on clinical grounds by the attending medical officer at a maintenance squadron.
The key symptoms were pain in the back and neck following a rugby injury.
The key signs were tenderness over the cervical and lumbar spine with paraspinal muscle involvement and over the left scapula, which overlies the upper thoracic cage [ [CHART REVIEW document], pages 16 17]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 1 December 2009 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: Soft tissue injury of the thoracic spine is not a diagnosis named in the SOP; it is assessed as a sprain and strain because the scrum collapse of 1 February 1990 injured the ligaments and muscles of his back, with pain from the time of injury and tenderness of the spine, the paraspinal muscles and the left scapula (which overlies the upper thoracic cage) when he was examined two days later.
The record names the cervical and lumbar spine rather than the thoracic segment itself.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - On 1 February 1990, during organised rugby at a maintenance squadron, a scrum collapsed on top of the veteran, 'injuring his back, shoulder and neck' according to the Compensation Supporting Report.
The weight of the collapsing scrum bore down along his spine, applying a significant physical force through the thoracic joints that lie between the injured cervical and lumbar segments.
On 3 February 1990 the Medical Officer found tenderness of the cervical and lumbar spine, the paraspinal muscles and the left scapula, with reduced range of movement, and diagnosed a ligamentous back injury, whose onset coincided with this force.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — MET - When the scrum collapsed on top of the veteran at a maintenance squadron on 1 February 1990, the paraspinal and shoulder girdle muscles of his back were forcibly stretched while contracting against the load.
The Daily Injury Record, completed when he was examined on 3 February 1990, records tenderness of the paraspinal muscles and over the left scapula, which overlies the upper thoracic cage, with reduced range of movement and three days' light duty.
The muscle injury of the thoracic region began with this forceful stretching.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament — MET - The Compensation Supporting Report of 1 February 1990 records that a scrum collapsed on top of the veteran during organised rugby at a maintenance squadron, injuring his back, shoulder and neck.
That force passed through the thoracic joints between the injured cervical and lumbar segments, and a ligamentous back injury with spinal, paraspinal and left scapular tenderness was diagnosed at that time.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon — MET - The scrum collapse of 1 February 1990 at a maintenance squadron forcibly stretched the paraspinal and scapular muscles of the veteran's back, and the Daily Injury Record records paraspinal and left scapular tenderness with reduced movement, so the muscle component of the thoracic injury began with this forceful stretching.
Other Plausible Links to Service The injury arose in the course of the veteran's employment.
The Compensation Supporting Report of 1 February 1990 records that he was on duty, in organised sport, when the scrum collapsed on him, at the age of 16 during initial recruit training at a maintenance squadron, which meets the DRCA test of an injury arising out of, or in the course of, employment.
Service later aggravated the injured region.
The upper back strain of November 1993, in the same left scapular region, deteriorated with climbing stairs in ships, and the fall onto a floor polisher on 5 July 1994 occurred on duty while he was scrubbing and polishing a deck; the incident of 23 November 1993 occurred, according to the Daily Injury Record, on his way home from work, although the same form ticks 'No' for duty and for travelling to or from duty.
Under the DRCA, an aggravation that arises out of, or in the course of, employment is itself an injury.
The veteran now has moderate multilevel thoracic spondylosis with facet arthropathy and disc protrusions (MRI of 18 August 2019).
The repeated in-service injuries to the thoracic region are a plausible contributor to that degeneration, alongside the sequelae of Scheuermann's disorder and his obesity, so the degenerative disease may in part be a sequela of this injury.
Conclusion the veteran's thoracic soft tissue injury was caused by the significant force of a rugby scrum collapsing on top of him on 1 February 1990, while he was on duty in organised sport as an Aircraft Technician at a maintenance squadron, which injured the ligaments and muscles of his back, including the left scapular region.
After onset, service aggravated the region through the car- jack incident and the shipboard aggravation of an upper back strain in November 1993 and a fall on duty in July 1994, and the thoracic spine was never investigated in service.
The injury arose in the course of his service and was aggravated by it.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's thoracic soft tissue injury is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (about 1 February 1990) aggravated it or contributed to it in a material degree.
He served for more than six years after that date.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Sprain and Strain, No.
28 of 2020) Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After February 1990 the veteran's thoracic region was subjected to further significant forces in service.
On 23 November 1993 a car slid off a jack and pinned him by the shoulders, with pain in the shoulder and 'spine' recorded, and on 5 July 1994 he slipped and landed on a floor polisher and his back on duty, bruising the right posterior ribs 9 to 12, which articulate with the lower thoracic vertebrae.
The region measurably worsened: an upper back strain was diagnosed on 30 November 1993, and the thoracic spine, first imaged for lower thoracic pain in February 2022, showed multilevel degeneration; a later non-service workplace fall on 8 June 2022 was followed by lower thoracic pain 'not abating'.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - On 30 November 1993 the Medical Officer diagnosed a strain of the left scapular and upper back muscles, the same region that was tender after the scrum collapse of February 1990, following an incident on 23 November 1993 in which a car slid off a jack and pinned the veteran by the shoulders, forcibly stretching these muscles.
The strain then deteriorated 'when he goes up & down stairs in ships', a high-intensity use of the same muscles during shipboard service.
The worsening was measurable: treatment was escalated from Brufen and heat to Voltaren 50 mg twice daily and Messal cream, and he was excused duty.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - the veteran's thoracic region was injured in service in February 1990, November 1993 and July 1994 and was managed each time with anti-inflammatory medication, cream or light duties, without thoracic imaging or specialist referral (the X-rays of July 1994 were of the ribs and lumbosacral spine).
The thoracic spine was first imaged in February 2022, 32 years after the first injury, when multilevel degenerative disc disease was found.
Sea service, a command signal of 24 October 1992 suspecting him of malingering and the loss of his medical record in July 1995 were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions, so this factor is met.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Sprain and Strain, No.
27 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament — MET - After February 1990 significant forces were again applied to the veteran's thoracic region in service, when a car pinned him by the shoulders on 23 November 1993 and when he fell onto a floor polisher on duty on 5 July 1994, bruising the lower posterior ribs.
An upper back strain followed in November 1993, and the thoracic spine later showed multilevel degeneration.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon — MET - In November 1993 the left scapular and upper back muscles, tender after the scrum collapse of 1989, were forcibly stretched when a car pinned the veteran by the shoulders and then worsened with climbing stairs in ships.
The Medical Officer diagnosed a muscle strain on 30 November 1993 and escalated treatment to Voltaren and Messal cream, with time off duty.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain — MET - the veteran's thoracic region was injured in 1989, 1993 and 1994 and treated only with medication and light duties, and the thoracic spine was not imaged until February 2022.
With sea service, the 1992 malingering signal and the loss of his medical record in 1995, this amounts to an inability to obtain appropriate clinical management under Brew v Repatriation Commission (Full Federal Court, 10 September 1999)
Sequelae
The thoracic soft tissue injury was the first of several in-service injuries to the thoracic region, followed by the car-jack incident and upper back strain of November 1993 and the fall of 5 July 1994.
These injuries are a plausible contributor to the moderate multilevel thoracic spondylosis later shown on imaging (MRI of 18 August 2019), alongside the sequelae of Scheuermann's disorder, a developmental condition, and obesity, so the spondylosis is in part a sequela of this injury
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
The veteran's thoracic region was injured in service in February 1990, November 1993 and July 1994 and was managed each time with anti- inflammatory medication, cream or light duties, without imaging of the thoracic spine or specialist referral (the X-rays of July 1994 were of the ribs and lumbosacral spine); the thoracic spine was first imaged in February 2022.
Sea service, a command signal of 24 October 1992 suspecting him of malingering and the loss of his medical record in July 1995 were further barriers.
As held by the Full Federal Court in Brew v Repatriation Commission (10 September 1999), inability is assessed objectively and subjectively and includes the threat of sanctions — MET
Date of Clinical Onset
Thoracic soft tissue injury is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately 1 February 1990 — ligamentous back injury sustained playing rugby at a maintenance squadron [ [CHART REVIEW document], pages 16 17].
The later records, including later thoracic imaging, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: approximately 1 February 1990.
This date falls within the veteran's ADF service (3 September 1989 19 June 1996).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
